Dyslexia and Neuroplasticity – A Literature Review

1. Dyslexia - Definition

Dyslexia, the most common learning disability, represents difficulties in learning to read
despite otherwise adequate overall intelligence, motivation, socioeconomic and educational
opportunities. In this respect, it can be stated that “Dyslexia represents a specific disability
within an ocean of competence” (A. Bragdon & D. Gamon, 2000, apud R. Dowson, 2003).
An inherited condition, dyslexia is a neuro-cognitive deficit that has been associated with
poor neurological communication between the left and right brain hemispheres that is not
caused by brain injuries. It is however often referred to as a developmental disorder and can
later in life be the result of a traumatic brain injury, stroke, or dementia (National Institute of
Neurological Disorders and Stroke, 2011).

In short, the most common learning disability, dyslexia, is considered a receptive language-
based learning disability characterized by difficulties with decoding, fluent word recognition,
rapid automatic naming, and/or reading-comprehension skills (Handler S. M., 2011).
Developmental dyslexia is considered as a neurobiological disorder characterized by a deficit
in the phonological component of language - speech sounds and relating them to print - along
with poor reading skills, in absence of other neurological disorders or cognitive deficits (Lyon
et al., 2003; Shaywitz et al., 2008, apud Conway et al., 2008). Moreover, dyslexia is
associated with deficient memory skills and specific deficits in auditory working memory
(AWM).

According to ICD-10 Version: 2015 (ICD-10 is the 10th revision of the International
Statistical Classification of Diseases and Related Health Problems, a medical classification
list by the World Health Organization that contains codes for diseases, signs and symptoms,
abnormal findings, complaints, social circumstances, and external causes of injury or
diseases), dyslexia or developmental dyslexia is defined within the category of F81 Specific
developmental disorders of scholastic skills, within the subcategory F81.0 Specific reading
disorders: “The main feature is a specific and significant impairment in the development of
reading skills that is not solely accounted for by mental age, visual acuity problems, or
inadequate schooling. Reading comprehension skill, reading word recognition, oral reading
skill, and performance of tasks requiring reading may all be affected. Spelling difficulties are
frequently associated with specific reading disorder and often remain into adolescence even
after some progress in reading has been made”. The definition also includes the fact that if left
unaddressed, dyslexia is often associated with emotional and behavioral disturbances during
the school age period.

The constellation of deficits underlain by dyslexia include not only a reading impairment, but
also deficits in phonological processing, short term and working memory, rapid auditory
processing and visual attention (Szalkowski, 2012). Other studies also show that the
behavioral manifestations of dyslexia are not restricted to language only. Although most
commonly described as involving deficits in phonological processing, letter naming, and
verbal working memory (Torgesen Davis, 1996; Wagner & Torgesen, 1987, apud Eden et al.,
2003), spatial construction deficits have also been observed, thus bringing data to support the
fact that children with dyslexia also suffer from visuospatial impairments such as aberrant
perceptions of contrast and motion under certain stimulus conditions (Lovegrove et al., 1986;
Stein, 1989; Williams & Lecluyse, 1990; Willows, 1991, apud Eden et al., 2003)
characteristic of right posterior parietal cortex. The left side neglect measured with the Clock
Drawing Test (Eden et al., 2003) suggesting a right-hemisphere dysfunction and the
phonological difficulties that point to left-hemisphere involvement point out that dyslexia
probably results from a developmental process that affects both hemispheres (Eden et al.,
2003).

Dyslexia and specific language impairment (SLI) are frequently comorbid with one another,
while many of the core impairments of these two language learning disorders overlap, which
lead to the development of an all-encompassing diagnosis of “language disability”(Tallal et
al., 1993; Peterson et al., 2007, apud Szalowski, 2012). A core affected behavior of this
umbrella diagnosis is rapid auditory processing, or deficits in processing rapid verbal and
non-verbal acoustic information, which have an important association with higher order
cognitive processes involved in reading (Banai et al., 2009; Fitch and Tallal, 2003; Tallal,
1980; Witton et al, 1998, apud Szalowski, 2012). Many earlier studies have demonstrated the
significance of early sensitivity to the phonological structure of words, while phonological
awareness – i.e. the ability to identify and manipulate phoneme-sized elements of spoken
language, is strongly related to early reading acquisition and can further predict correlates
such as intelligence, vocabulary, listening comprehension, and remain an important predictor
of reading achievement even after eliminating intelligence and verbal ability (Hoien T,
Lundberg I, Stanovich K, Bjaalid IK (1995) Components of phonological awareness. Reading
and Writing 7:171–188, apud G. Schulte-Körne et al., 1999).

However, the rapid auditory processing deficits are accompanied by impairments in short
term memory and visuospatial attention that have an important role in language and reading
(Beneventi et ai, 2010; Bishop, 2009; Fitch and Szalkowski, 2012; Franceschini et al., 2012;
Gabrieli and Norton 2012; Gathercole et al., 2006; Menghini et al., 2010, 2011; Smith-Spark
and Fisk 2007, apud Szalowski, 2012).

Regarding rapid auditory processing, studies suggested that pre-reading deficits in the
discrimination of two distinct tones can serve as significant predictors of a future diagnosis of
language impairment in children with a family history of language disability (Benasich et al.,
2002; 2006; Choudhury et al., 2007, apud Szalowski, 2012). Furthermore, deficits in short
term and working memory have been observed in dyslexics, while language impaired
individuals have been found to exhibit impairments in verbal working memory (Archibald
and 4 Gathercole 2006; Gathercole et al, 2006; Smith-Spark and Fisk, 2007, apud Szalowski,
2012). Also, deficits in visuospatial processing and non-verbal visual memory have been
detected in individuals with dyslexia, demonstrated in visual pattern sequence recall tasks
such as the Corsi block span test and the visual patterns test. Visuospatial attention deficits in
language impaired individuals have also been detected (Araujo, 2012; Facoetti et al., 2010;
Franceschini et al., 2012; Gabrieli and Norton, 2012; Lobier et al., 2012; Peyrin et al., 2012;
Ruffino et al., 2010; Shaywitz and Shaywitz, 2008, apud Szalowski, 2012), characterized
mostly as impairments in attentional engagement and attentional shifting during computerized
task performance. The high comorbidity with ADHD discussed below also supports the
interaction between attention and reading ability.

According to Dowson (2003), identifying dyslexia includes finding a set of patterns of

characteristics that interact in association with a student having difficulty to learn, write and
spell. Some common characteristics are: difficulty differentiating between letters and other
symbols; difficulty reading and identifying the phonetic structure of a word; avoidance
reading and specially oral reading in class; enjoyment of limited success on written academic
tests; satisfaction on verbal test administration success; giving up under the pressure of a
timed test; belief of inferiority in intelligence; continual failure at school resulting in low self-
esteem; behavioral problems; hiding of learning disability; not showing enough effort or
interest in class despite average or above average intelligence; exhibiting of a special talent
and/or interest in arts, manual work or sales, business or driving; difficulties copying words or
sentences; variations in the readability of handwriting; poor or inconsistent spelling; difficulty
with tasks requiring fine motor skills but outstanding ability with visual images; null IQ test
results on tests with a time limit and extensive reading; or a variance of 15 percent or more
between verbal and spatial tests within IQ testing (Dowson, 2003).

Dyslexic children fall out on multiple different tasks and modalities, which are described
through interaction-dominant dynamics – specific component deficiencies are not assumed to
underlie developmental dyslexia, but rather a much more general reduction of system
interactions and coordination among multiple task-specific processes. Developmental dyslexia
shows itself in many different facets of performance, because the linguistic, perceptual,
motor, and physiological processes involved in fluent reading interact massively. Trial-by-
trial variability in reading performance in dyslexics brings considerable information about the
system under scrutiny. The cognitive organization under scrutiny can be described as not so
much as a serial chain of processing components, each adding independently to the duration
of each reading or auditory response, but more one of characterizing levels of
interdependence in entangled cognitive phenomena. The system dynamics underlying
dyslexic reading performance are less confined, patterned, complex, and stable than dynamics
underlying non-dyslexic reading performance (Wijnants et al., 2009).

2. Comorbidity and Prevalence

Developmental dyslexia is considered the most common learning disability in the US and the
UK, accounting for 80% of all learning disabilities and affecting 5% - 17% of the population
(Katusic et al., 2001; Shaywitz et al., 1990, apud Eden G. et al., 2004).

The terms ‘dyslexia’ and ‘reading disability’ are often used interchangeably. The
comprehension process remains intact whereas decoding difficulties are more prominent.
There is a distinction between low-IQ and high-IQ individuals with dyslexia, where genetics
has been found to contribute more to high-IQ than to low-IQ dyslexia (Peterson &
Pennington, 2012). A gender discrepancy in the prevalence of dyslexia has also been
discussed, where a significant male predominance exists (3:1), and the sex difference in
referred samples is higher (3-6:1). According to some studies, dyslexia affects around 7% of
the population (Peterson & Pennington, 2012), or between 5 and 12 percent of all students
(Dowson, 2003), while half of all special education students are dyslexic. More clinical
attention is received by boys with dyslexia as they also have higher rates of comorbid
externalizing disorders such as attention-deficit hyperactivity disorder.

Cross-linguistic studies show that the neural correlates of poor reading seem to be very
consistent across cultures, and similar syllable processing deficits characterize dyslexia in
English, Spanish and Chinese. Dyslexia exists in all the studied languages, and phonological
awareness is a key predictor of reading skill in both more and less consistent orthographies
(Peterson & Pennington, 2012).

Today there is a debate as to how separable are different comorbid diagnoses within the wide
variety of developmental learning disabilities (including attention-deficit/ hyperactivity
disorder, autism spectrum disorder, specific language impairment and dyslexia), which all are
concomitant with auditory processing disorder (APD), where there is a mismatch between
peripheral hearing and the ability to interpret, discriminate, and sequence sounds (Tallal P.,
2012).

Developmental dyslexia occurs comorbidly with autism, however they occupy opposing
extremes on a neuro-morphological distribution, which translates into divergent etiologies.
Dyslexia appears in conjunction with an autistic spectrum condition (ASC), seemingly being a
secondary disorder that has more in common etiologically with the overarching ASC than
with the form of dyslexia occurring separately. Therefore, developmental dyslexia without
comorbid autism is called as “primary dyslexia” and the comorbid form as “secondary
dyslexia” (Williams, 2012).

As also seen in autism, epilepsy is significantly associated with dyslexia and may have similar
roots in the occurrence of heterotopias (the presence of a particular tissue type, for example
gray matter, at a non-physiological site – in the wrong part of the brain) and dysplasias
(enlargement of an organ or tissue by the proliferation of cells of an abnormal type)
(Williams, 2012). Identifying inborn errors of corticogenesis could help differentiate and
pinpoint their respective etiologies.

In the case of primary dyslexia, studies showed increased minicolumnar width, mean cell
spacing, and neuropil width as compared to control subjects. Reduced gyal complexity,
increased gyral window size, and increased corpus callosal volume have also been found,
along with focal reductions in gray and white matter volumes such as within the leftmiddle
and inferior temporal gyri and arcuate fascilulus; an unusual symmetry between the left and
right plana temporale; and an overall reduction in the total brain volume. Cortical heterotopias
and dysplasias were also noted, particularly within the left hemisphere.

3. Etiology and Diagnosis

The etiology of dyslexia is multifactorial and reflects genetic influences as well as

dysfunction of brain systems. Early recognition of the deficit in the phonologic component of
language that makes it difficult to use the alphabetic code to decode the written word, along
with referral to qualified professionals for evidence-based evaluations and treatments are
necessary in order to achieve the best possible outcome.

Understanding the causal factors in dyslexia is critical for early intervention and successful
treatment of reading disability. While the causal mechanisms remain a matter of debate, the
most widely accepted explanation for dyslexics’ reading problems refers to weakness in
phonological coding – isolating and manipulating sounds within words (Vellutino et al.,
2004), other theoretical models are still being tested. The possibility that deficits manifested
in the magnocellular-dominated dorsal visual system are either causal or consequential to
reading disability was tested in a study by Olulade et al. (2013). Using fMRI (functional
magnetic resonance imaging), the study demonstrated a relation between reading ability and
activity in brain area V5/MT during visual motion processing, with an impoverished reading
ability in dyslexics corresponding to a lower activity in V5/MT. However, this relation was by
no means found to be causal, with the altered visual magnocellular function representing
merely an epiphenomenon of dyslexia – that is, a side effect of dyslexia, emerging along with
other deficits – a sensorimotor syndrome (a variety of symptoms: linguistic, sensory and
motor) that are the primary cause of the reading problem (Ramus, 2004). Other behavioral
and brain imaging studies have shown on the other hand that there is a causal relationship of
phonological awareness on reading (Hoeft et al., 2006 & 2007), with beneficial effects on the
reading abilities after phonological training (Eden et al., 2004).

There is rather strong evidence from neuroimaging studies using event-related potentials,
magnetoencephalography, or functional magnetic resonance imaging, for changes in
hemispheric asymmetry in dyslexics during both visual and auditory processing of speech and
non-speech stimuli (Heim, 2010). At the same time, a larger set of variables gradually
contribute to brain activation during dyslexic and normal reading, which suggests the
existence of cognitive types of dyslexia (for example dyslexic reading is associated with
different cognitive performance patterns when phonological awareness, visual attention and
other variables are considered), also sustained by the fact that different cognitive variables
show co-variation with partly different brain regions – a different effect between dyslexics
and normal readers. Whereas normal readers’ brain activation during reading show co-
variation effects predominantly in the right hemisphere, the reverse pattern is observed for
dyslexics, which supports earlier findings in the literature that a global change occurs in
hemispheric asymmetry during cognitive processing in dyslexic readers, which might in turn
affect reading proficiency. These findings suggest that a broader empirical base is needed
with respect to cognition, which may then motivate developmental neuroimaging studies
investigating brain-cognition relationships in dyslexia.

In neuroscience, a wide range of anatomical differences is held to differentiate between

children with developmental dyslexia and average readers, including reductions in temporal
lobe, frontal lobe, caudate, thalamus and cerebellum (Brown et al., 2001), insula, anterior
superior neocortex, posterior cortex (Pennington, 1999), occipital cortex (Eckert et al., 2003)
and relative increases in the size of temporal and parietal plana (Green et al., 1999). The
variety of brain regions implicated in dyslexia makes it highly difficult, if not impossible, to
pinpoint a single deficient region or component of the brain whose malfunctioning uniquely
leads to developmental dyslexia. Becoming literate is a highly complex task that is irregular
and serves under other linguistic and cognitive abilities, which makes it into a multifaceted
process (Wallot & Van Orden, 2011a), which suggests that successful reading may emerge
from a multitude of interdependent processes (e.g., Holden, Van Orden, & Turvey, 2009;
Kello & Van Orden, 2009, apud. Wijnants, 2012). On the same note, a study by Gawron
(2014) presents research evidence on the deficits of dyslexic children in a number of
processes including coherent motion detection, automatization, attention shifting, visual
attention span, and anchoring.

Study results suggest that the deficits in pre-attentive speech processing can be considered a
cause of dyslexia (G. Schulte-Körne et al., 1999). Neuroimaging in children with dyslexia has
revealed reduced engagement of the left temporo-parietal cortex for phonological processing
of print, altered white-matter connectivity, and functional plasticity associated with effective
intervention (Gabrieli, J.D.E., 2009). Further study results (Centanni, T.M., 2014) show that
individuals with dyslexia score more than a standard deviation below their peers on reading
tests and have deficits in phoneme perception and manipulation, while neural activation
during phonological processing is impaired in young children even before learning to read.
This suggests that the neural abnormalities responsible for dyslexia are present from birth,
which is supported by the fact that dyslexia is highly heritable and at least four candidate-
dyslexia genes have been identified: KIAA0319, DYX1C1, DCDC2 and ROBO1. KIAA0319
is the gene most consistently associated with dyslexia, and variants in KIAA0319 impair
speech evoked cortical activity and cause poor speech perception and reading ability, which
confirms that phonological processing is a core deficit in dyslexia (Centanni, T.M., 2014). A
variation of this gene also duplicates corpus callosum abnormalities in dyslexia without
changing body weight or the volume of the cortex and hippocampus. Behavioral training has
however positive effects on neural responses to auditory stimuli, as KIA-auditory cortex firing
properties change as a result of the training. Dyslexics also have reduced cortical and
thalamic responses to non-speech sounds and speech sounds in passive and active listening
conditions, while the trial-to-trial variability for auditory responses in the brainstem is
significantly elevated in children with dyslexia (Centanni, T.M., 2014).

Recent studies restrict the diagnosis of dyslexia to a stringent criterion of a phonological

deficit, while older studies including the most highly cited of postmortem studies report either
vague diagnostic inclusion criteria or base diagnosis on a broader reading deficit. Therefore it
is argued that dyslexia as diagnosed and known today, which has roots in faulty speech
processing, is not the same as the general reading deficit studied in earlier research (Williams,
2012). Due to the fact that abnormalities have been found in the magnocellular pathway, a
visual pathway which processes rapid low-contrast visual information, dyslexics have been
found to tend to perform poorly on tasks of rapid visual processing. The fundamental
underlying deficit in dyslexia would thus lie not within a given sensory modality but with the
rapid processing of information that bears its roots within the thalamus (Livingstone et al.,
1991). Neocortical anomalies appear to promote the thalamic ones (Galaburda, 1999). While
other symptoms may be secondary to dyslexia, such as abnormalities in visual and sensory-
motor processing, research suggests that deficits in phonological decoding are the primary
cause in the reading impairment that defines dyslexia.

The separation of etiologically different reading disorders in the criteria list – for example
presenting the co-occurence of secondary dyslexia with autism separately from primary
dyslexia, or a disorder of reading comprehension separately from the classic dyslexia, as well
as separating the underlying deficits – e.g., reading comprehension versus word recognition,
would benefit diagnostic and treatment methods in helping individuals improve their reading
skills with precisely tailored programs (Williams, 2012).

Diagnosing learning disabilities – dyslexia included, should begin in the early school years, as
it involves a complex process. A four step screening system for learning disability is
recommended by Gilbert et al. (2012, apud Hategan et al., 2015) where the first step is a static
screening instrument including letter identification, oral reading fluency, phoneme
segmentation, and word identification for students in kindergarten or first grade. The second
step would involve monitoring fluency in letter identification, passage reading, and word
identification. The third step is follow-up testing using standardized, nationally normed test,
and state achievement test; and the fourth test includes upgrading procedures for subsequent
years. McInnis et al. (2011, p. 184, apud Hategan et al., 2015) conclude that there I some
consistency in England with the use of the WAIST-III-UK and preference for the ABAS II
where formal tools are used.

4. Neuroplasticity in Dyslexia

As a definition, neuroplasticity refers to the ability of the nervous system to respond to

intrinsic or extrinsic stimuli by reorganizing its structure, function and connections.
Neuroplasticity occurs in many forms, contexts and variations, while common themes that
emerge across different central nervous system conditions include experience dependence
(modifiable through interventions, training-induced cognitive and motor learning), time
sensitivity and the importance of motivation and attention (Cramer S. C., 2011).
Neuroplasticity-based changes in this context mean that the training is in accord with
neuroscience studies of how brain areas reorganize through training. Rehabilitation
interventions of cognitive and sensorimotor skills rely on models of neural plasticity and
recovery of function derived from research on animals, whereas the brain’s capacity to
reorganize itself in response to acute or developmental injuries is crucial for these
interventions.

According to studies by Luria (1980), who focused on the interconnection of various

functional brain systems, damage to one brain area, or structure, will lead to disturbances in
all the complex behavior processes that involved that area. Thus it has been found that
damage to the premotor zone will lead to disturbances in three functional systems that include
writing, speaking and arithmetic and the automatic mental activity they involve. All of these
processes, that seem to have nothing in common, are actually affected by the same lesion to
the parieto-tempero-occipital zone in the left hemisphere, according to Luria (1980), along
with the integration of details in a single pattern, the recognition of relationship or
connections, and the unification of individual elements into a single system.

Training-induced changes have been demonstrated in adults with acquired language and
reading deficits, where increased activity in right hemisphere temporal regions in response to
rehabilitation, homologous to the dominant hemisphere areas typically engaged in tasks of
reading (Adair et al., 2000, apud Eden G. et al, 2004) and comprehension (Musso et al., 1999,
apud Eden G. et al, 2004) have been reported. Neuroplasticity has further been reported in
using phonologically based reading intervention which caused a shift from left interior
parietal region cortex to the left fusiform gyrus in a stroke patient (Small et al., 1998, apud
Eden G. et al, 2004). Studies of developmental dyslexia in children who received
phonological based reading remediation have demonstrated that reading improvement is
associated with the “normalization” of previously underactivated left hemisphere brain
regions (Aylward et al., 2003; Richards et al., 2000; Shaywitz et al., 2004; Simos et al., 2002,
apud Eden G. et al, 2004).

Positron emission tomography (PET) and functional magnetic resonance imaging (fMRI)
studies revealed the neural signature of both adult normal reading (Bookheimer et al., 1995;
Fiez and Petersen, 1998; Price, 1997; Pugh et al., 1996; Turkeltaub et al., 2002, apud Eden G.
et al., 2004) and phonological processing (Gelfand and Bookheimer, 2003; Poldrack et al.,
1999; Price et al., 1997; Rumsey et al., 1997a, apud Eden G. et al., 2004). Consistently, brain
imaging studies have also characterized the anomalous patterns of neuronal activation
associated with reading and phonological processing in adults with persistent or compensated
developmental dyslexia (Brunswick et al., 1999; Demonet et al., 1992; Flowers et al., 1991;
Horwitz et al., 1998; Ingvar et al., 1993; Paulesu et al., 1996; Pugh et al., 2000; Rumsey et al.,
1997b; Shaywitz et al., 1998, apud Eden G. et al., 2004), where dysfunctional phonological
processing in dyslexia was localized in left-hemisphere perisylvian regions. Where
nonalphabetic scripts are involved and reading places less demand on phonemic processing
and the integration of visual-ortographic information is crucial, dyslexia was associated with
underactivity of the middle frontal gyrus (Siok et al., 2004, apud Eden G. et al., 2004).
Moreover, these problems persist in adulthood if left unaddressed.
Phonologically-based training in adults with persistent dyslexia lead to measurable gains in
phonological processing skills that in the same time transfer to some aspects of the reading
ability and leads to improved accuracy on non-word decoding and oral paragraph reading.
Furthermore, the improved phonological awareness indicates a dual neurobiological
mechanism that reports changes through increased activity of the left parietal cortex (as
observed by typical readers), as well as through compensatory mechanisms in the right
hemisphere perisylvan regions (parietal cortex), which supports the fact that behavioral
plasticity in adults with developmental dyslexia is supported by an increased engagement of
the normal left hemisphere and a compensatory mechanism wherein new areas are recruited
within left or right hemisphere in the form of a functional recovery.

Post-mortem neuroanatomic investigations of adults with developmental dyslexia show

perisylvian regions with aberrant neuronal structures, which may be developmental in nature,
originating in utero (Galaburda et al., 2006; Ramus, 2004, apud Conway, 2008). This
suggests that atypical neuronal activity may be evident in these language cortices during
neuroimaging investigations of AWM (auditory working memory). Furthermore, readers
without dyslexia show greater left temporoparietal activity, with only minimal working
memory demands in left fusiform gyrus and Broca’s region, left superior temporal gyrus and
bilateral operculum during neuroimaging studies, while dyslexic individuals show higher
activity in the medial temporal lobe during syllable identification. Thus, neuroimaging studies
imply that temporal and parietal regions may demonstrate anomalous activity in adults
diagnosed with dyslexia. A study that used fMRI during linguistic (pseudoword) and non-
linguistic (pure tone) AWM (auditory working memory) tasks to identify patterns of neural
activity between adults with and without developmental dyslexia in order to identify if neural
substrates of auditory working memory varied between dyslexics and non-dyslexics for one or
both types of stimuli found evidence of differential cognitive abilities between the two
groups. The individuals diagnosed with dyslexia showed deficits in phonological awareness
and AWM for linguistic stimuli that were not explained by performance accuracy, which
implies underlying differences in the neural substrates of task performance. Furthermore,
individuals with dyslexia showed greater activity than normal readers in left primary and
secondary auditory cortex for both linguistic and non-linguistic stimuli and a “weak left-
hemisphere bias at this phonological level of processing” (Hickok & Poeppel, 2007, apud
Conway, 2008).
The right inferior frontal gyrus was shown (Hoeft F. et al., 2011) to compensate for problems
in learning to read, as dyslexic readers who show gains in reading do so by depending on a
right-hemisphere pathway, in contrast to the left-hemisphere pathway that characterizes
typical reading. Right-hemisphere plasticity is however apparent after one year of
remediation. This is sustained by another earlier study (Shaywitz SE et al., 2003) where
activation in the right superior frontal gyrus for a phonological task was greater in
compensated compared with persistently poor readers.

According to estimates by Ramus (2003), the incidence of visual deficits in dyslexia is around
29%; the incidence of auditory deficits is around 39%, and the incidence of motor deficits is
around 50%, while the incidence of phonological deficits and processing speed deficits is
more than 90%. While there is still no clear consensus on appropriate methods of diagnosis
and treatment and the apparent isolation in which research into different development disorder
has effectively developed from others, there needs to be a convergence in terms of cognitive
neuroscience and pedagogical methods. Fawcett (2007) suggests an approach where first the
learning disabilities that underlay the ‘specific learning difficulties’ of dyslexia are identified
at a cognitive level, after which the cause (in terms of brain function) to why this problem
arose is identified. Studies showed that training in phonological awareness was helpful for
children with dyslexia, but this training is not as helpful as a more rounded approach
involving fluency as well as phonology. Interventions that aimed to improve magnocellular
function, as well as attempts to improve motor and cerebellar function have proved to be more
controversial (cerebellum is the brain structure most centrally involved in automatization and
centrally involved in language skills and motor skills). Genetic studies (Fisher, 2003; for other
studies see Fawcett, 2007) have shown potential abnormalities at chromosomal level, with
strong evidence for chromosomes 15, 6, 2,3 and 18, which leads to the conclusion that there
must be different subtypes of dyslexia at the genetic level. Fawcett (2007) proposes that
developing brain-based and genetic methods is crucial in order to design individually-
appropriate remediation and treatment methods.

Helland (2007) studied dyslexic students with mathematics impairment but not language
comprehension impairment, who had a weak phonological loop along with impaired visual
skills. A subgroup of students with dyslexia, who did not have language comprehension
impairments or mathematical impairments, had evident deficits in the retrieval process within
the phonological loop. Another group of dyslexics with impaired language comprehension
demonstrated weakness within the phonological loop but normal visual skills. According to
these results, Helland proposed that intervention should focus on the students’ assets to
support the specific deficits of dyslexics, as differences in dyslexia at a cognitive level impact
differences at a behavioral level, as exhibited by functional reading and writing.

A review (Hornickel J. et al., 2012) of assisted listening devices and neuroplasticity studies in
children with dyslexia reported that children with dyslexia show inconsistent
electrophysiological response to speech sounds at the level of the brainstem, and that using a
classroom assistive listening system leads to significant improvement in the consistency of the
neural response coupled with improvement in phonological awareness and reading skills.

A study on the cerebellar function (Stoodley & Stein, 2013) considers developmental dyslexia
to be a genetically based neurobiological syndrome, where even remediated dyslexic readers
rarely achieve fast, fluent reading. Dyslexics also present impairments in attention, short-term
memory, sequencing (letters, word sounds and motor acts), eye movements, poor balance and
general clumsiness, which represent cerebellar motor and fluency symptoms. FMRI studies
showed that the cerebellum is part of the neural network supporting reading in typically
developing readers, and that patients with cerebellar damage (cerebellar asymmetry and
differences in gray matter volume) show reading difficulties. Some dyslexics show poorer
performance on cerebellar motor tasks – including eye movement control, postural stability
and implicit motor learning. Due to the fact that many dyslexics do not have any cerebellar
symptoms however, differences in dyslexic brains are not isolated to cerebellum, and many
cerebellar patients do not have reading problems, it is argued that impaired cerebellar function
is probably not the primary cause of dyslexia, but rather a more fundamental neuro-
developmental abnormality that leads to differences throughout the reading network.

5. Treating dyslexia in educational environments

The varieties of individual deficits presented, along with the difficulty in diagnosing severe
reading difficulties and differences in learning (Pennington, 1990, apud Goldstein & Obrzut,
2001) has resulted into different intervention strategies instead of a singular consistent and
effective way to remediate dyslexia. Generally described as mild to severe reading delay,
dyslexia has been approached by efforts to effectively teach children to read. Some commonly
used techniques include the Language Experience Approach (LEA; Stauffer, 1951, apud
Goldstein & Obrzut, 2001), the whole word method (Betts, 1943, apud Goldstein & Obrzut,
2001), and the linguistic approach (Marsh, Freedman, Welch, & Desberg, 1981; Marsh,
Freedman, & Desberg, 1983, apud Goldstein & Obrzut, 2001). The LEA uses storytelling in
teaching reading and vocabulary to the reader, the whole word method attempts introducing
meaningful words into a reader’s lexicon for the purpose of increased recognition, while the
linguistic approach defines a set of rules that regulate the way sounds and letters correspond.
These procedures have not produced consistent reading improvement according to Kappers
(1997, apud Goldstein & Obrzut, 2001), possibly due to the fact that these methods are not
based on the brain processing relationship that is dysfunctional and the neuropsychological
deficiencies in dyslexia. Most of these inefficient procedures focused on strategy and
cognitive development and not on neuropsychological approaches in treating dyslexia.

Different neural mechanisms and pathways than those that support gains in reading for
typically developing children are reflected in children with dyslexia (Hoeft, 2011), which
encourages consideration of intervention approaches that focus on alternative reading
strategies in addition to interventions that build on typical reading instruction. Brain measures
also seem to be more predictive of the prognosis of advancement in reading skills than
behavioral measures, which may have implications for the future identification of relevant
treatments.

A study (Schneps et al., 2012) of dyslexics who face lifelong struggles with reading found
that they perform significantly better compared to typical readers in contexts of low-pass
filtered natural scenes, which suggest that perception or memory for low spatial frequency
components in scenes is enhanced in dyslexia. This suggests that using spatial learning for
dyslexics who are otherwise impaired provides important training strengths, which conducts
to implications for the education and support of students who face challenges in school.

An alternative intervention strategy based on a presumed weakness in hemispheric processing

(Bakker, 1990) includes visual perception in addition to phonological skills emphasis.
Reading techniques that integrate visual analysis are typically limited to word recognition and
are not analytical or involve sequential decoding (Licht & Spyer, 1994, apud Goldstein &
Obrzut, 2001). Bakker’s revised method involves the perceptual recognition of features
present in different letters or graphemes that are subsumed by functions in the right
hemisphere, and is based on the hypothesis that dyslexia is caused by an over- or under-
development of one of the cerebral hemispheres, which burdens the compensating intact
hemisphere. The hypothesis was tested through electrophysiological studies that confirmed
the hemispheric shifts in development, where dyslexic individuals showed insufficient
functioning either in the left or the right hemisphere, which resulted in nonfluent errors, lack
of retention of sufficient information from the story (right hemisphere), slow and laborious
processing of words, and excessive attention to detail to each letter (left hemisphere). More
current functional imaging studies in reading development further showed deficits in specific
brain regions, such as planum temporale symmetry or angular gyrus dysfunction instead of
developmental hemispheric changes that lead to dyslexia (Galaburda, Sherman, Rosen,
Aboitz, & Geschwind, 1985; Plante, Boliek, Binkiewicz, & Erly, 1996; Rumsey, Andreason,
Zametkin, & Aquino, 1994, apud Goldstein & Obrzut, 2001).

The term visuoperceptual analysis refers to identifying letters and their particular features
(Van Strien, Bakker, Bouma, & Koops, 1994, apud Goldstein & Obrzut, 2001). Bakker also
attempted to classify readers with dyslexia by their error patterns, which may be important for
designing individualized treatments. Thus, there are P-type (perceptual) dyslexia and L-type
(linguistic) dyslexia. According to Bakker’s balance model to treat dyslexic readers in a
clinical setting, the primary components used are hemispheric specific stimulation (HSS)
and hemispheric alluding stimuli (HAS). HSS involves the presentation of words through a
computer-simulated program into the right visual field (RVF) or the left visual field (LVF) or
through tactile and perceptual exercises that activate each specific hemisphere. Thus the
recommendation is that individuals with P-type dyslexia should be presented with abstract
words to the RVF, whereas individuals with L-type dyslexia should be presented with
concrete words to RVF, according to previous studies that revealed that typical readers
reported a RVF advantage for abstract words and a reduced or absent RVF advantage for
concrete words (Dryer, Beale, & Lambert, 1999, apud Goldstein & Obrzut, 2001). HSS
involves constructing words letter by letter in different fonts in order to activate
visuoperceptual analysis, a component of the right hemisphere. The P-type dyslexic
individuals read text that consists of semantic and rhyming exercises from a passage, which
should initiate left hemisphere functioning.

While the HSS treatment proved itself efficient in reading and spelling accuracies for children
with L-type dyslexia, and showed no improvement in Bakker’s studies for children with P-
type dyslexia, the HAS method effectively improved reading for both groups of children.
According to Goldstein & Obrzut (2001), the validity of Bakker’s neuropsychological
intervention approach and previous testing results is supported, whereas the children with L-
type dyslexia demonstrate the greatest improvement in comprehension, followed by children
with P-type dyslexia and those with M-type (mixed-type) dyslexia.

A successful intervention procedure of 3 hours tutoring over a period of 8 weeks that resulted
in measurable positive effects in adults with dyslexia is a phonologically based commercial
program delivered at Wake Forest University Medical Center, which utilizes auditory, visual
and sensorimotor stimulation in a highly structured manner – “the multisensory approach”,
that was widely employed by special education tutors to remediate dyslexic students (Birch,
1999, apud Eden G. et al., 2004). This method includes sound awareness, establishment of the
rules for letter-sound organization, sensory stimulation, and articulatory feedback (Lindamood
and Lindamood, 1971, apud Eden G. et al., 2004). Imagery strategies were also used to help
visualize and manipulate letters and words, thus reinforcing the relationship between sounds
and printed letters and words and increasing both phonological processing and single-word
reading skills in children (Torgesen et al., 2001; Wise et al., 1999, apud Eden G. et al., 2004)
and adults (Alexander et al., 1991; Truch, 1994, apud Eden G. et al., 2004).

Extensive auditory therapy has been used to treat children with dyslexia by using
acoustically modified speech stimuli to improve phoneme awareness. The training can cause
changes in neural responses at multiple stages of the auditory pathway, which supports the
hypothesis that auditory training can induce therapeutic neural plasticity in dyslexia (Russo
NM, 2005). Collected neurophysiology data also demonstrates that behavioral training
improves neural discrimination of consonants and reduce the neural variability in genes
highly associated with dyslexia, which provides potential neural justification for the
widespread use of intensive auditory training for dyslexia (Centanni TM, 2014).

Fast ForWord is a training program provided by Scientific Learning Corporation, which

offers a web-based platform that helps students develop memory, attention, information
processing, and information sequencing skills, includes applications for oral language
comprehension and listening, reading comprehension, phonetics and grammar. The programs
use patented technologies to adapt to each student’s skill level. The program is based on 25
years of scientific research (Business Wire, 2002), including neuroscience, in preventing
reading difficulties in young children through game-like exercises in sets of 20 to 40 sessions
in order to achieve a “significant improvement as measured by the STAR Reading
assessment” in both math and reading scores.
Fast ForWord software is marketed as a proven scientifically based reading intervention
product that can significantly improve brain processing efficiency and reading skills
according to scientifically based research in education and empirical obtained data from
independent educational organizations.

Previous fMRI (functional magnetic resonance imaging) studies (Gaab N et al., 2007) have
shown that physiological differences in children with dyslexia can be alleviated through
remediation. Children with typical reading skills have greater activation in the prefrontal
cortex when exposed to rapid transitions than when exposed to slow transitions, whereas
children with dyslexia do not have this differentiated activation, which suggests that the brain
of a child with dyslexia is not representing fast and slow sound changes differently. Using
Fast ForWord in improving rapid auditory processing and phonological and linguistic training
– for example, discriminating between paired sounds, syllables or words -, resulted in
differentiated activation to rapid and slow transitions, similarly to that of children with typical
development (http://www.scilearn.com/resources/brain-fitness/sound-training-rewires-
dyslexic-childrens-brains-for-reading).

Other fMRI studies showed that there are differences in cortical activation of children with
and without dyslexia, which are diminished following Fast ForWord participation (Temple E.
et al., 2003). The differences pertain to phonological awareness tasks, where the left
hemisphere of children with typical development had more coherent activation in cortical
regions critical to reading than children with dyslexia.

Further studies (Eden G. et al., 2004) have been conducted on neural changes following
remediation in adult developmental dyslexia, where the differences in brain activity during a
phonological manipulation task before and after a behavioral intervention (tutored compared
to nontutored dyslexics) in adults with developmental dyslexia have been researched. The
effects of the intervention included signal increases in bilateral parietal and right perisylvian
cortices, which demonstrate that behavioral changes in tutored dyslexics are associated with
increased activity in the left-hemisphere regions engaged by normal readers and by
compensatory activity in the right perisylvian cortex.

Fast ForWord’s effects are sustained by a number of studies. A study by Stevens C. et al.
(2008) showed that children both with and without language impairments significantly
improved receptive language and selective attention through computerized training applied
through Fast ForWord for six weeks. An in-depth analysis (2010) of the Fast ForWord
program conducted by the Nevada Department of Education reported an increase in student
reading achievement by a average of 22.2 percentage points, the greatest increase of all the
programs reviewed. Another longitudinal study of the effects of Fast Forword on student
performance (Divine, K.P. & Botkin, D., 2008) concluded that 53.2% of Fast ForWord
participants made expected gains. Another recent study (Rogowsky, B., 2010) showed that
middle school students improved writing skills by using Fast ForWord.

Handler et al. (2011) reports that scientific evidence does not support the claims that visual
training, muscle exercises, ocular pursuit-and-tracking exercises, behavioral/perceptual vision
therapy, training glasses, prisms, and colored lenses are effective treatments for learning
disabilities including dyslexia, as children with dyslexia or related learning disabilities have
the same visual function and ocular health as children without such conditions.

According to an analysis by Tallal (2012), an increasing number of studies demonstrate that

rapid and significant improvement in reading can result from auditory interventions, and thus
children with language learning impairments - including dyslexia - respond inconsistently to
the rapidly changing spectrotemporal acoustic cues in speech, and this response becomes
more consistent after auditory intervention. Furthermore, the greater right prefrontal
activation during reading tasks that require phonological awareness and right superior
longitudinal fasciculus (including arcuate fasciculus) white-matter organization can
significantly predict future reading gains in dyslexia, where no other behavioral measure,
including widely used and standardized reading and language tests can make reliable reading
gains predictions in dyslexia (Hoeft, F., 2011).

A study (Loeb et al., 2009) examined the efficacy of Fast ForWord Language (FFW-L) and
two other interventions for improving the phonemic awareness and reading skills of children
with specific language impairment with concurrent poor reading skills. The children that
received either FF-L computerized intervention, a computer-assisted language intervention
(CALI), an individualized language intervention (ILI), made significantly greater gains in
blending sounds in words compared to children that received an attention control (AC)
computer program intervention, at immediate posttest. Long-term gains 6 months after the
treatment were not significant but yielded a medium effect size, and none of the interventions
led to significant changes in reading skills. These results suggest that FFW-L, CALI and ILI
interventions have limited use with children who have language impairment and poor reading
skills, although phonemic awareness is achieved. In the same study, across treatment
conditions suggest that acoustically modified speech is not a necessary component for
improving phonemic awareness.

The Arrowsmith Program is built on a base of studies done by Luria (1980), which suggest
that the neurological impairment - the source of a learning dysfunction, is the weaker
functioning by a specific brain area, which impairs the mental activities of the functional
systems in which this area is involved. The program includes cognitive exercises to strengthen
and enhance the cognitive capacities that underlie each dysfunction. A distinction is made
between learning dysfunction – problems stemming from deficits in particular areas in the
brain, and the learning disorders: for example learning difficulties that different kinds of
dysfunctions might contribute to these – motor symbol sequencing, problems with auditory
speech discrimination, or comprehension problems. The method, which was created by
Barbara Arrowsmith Young, aims at treating the 19 specific learning dysfunctions identified
through clinical research by increasing the capacity of specific mental components that they
are connected to.

The Arrowsmith method attempts to use a neuroscientific model based on the hypothesis that
deficient or weaker mental components are the source of learning dysfunctions, while each
learning disability is composed of five or more such dysfunctions. Early studies found
through a method called brain electrical mapping that “when compared with normal children,
the dyslexic group showed stronger alpha waves (thought to show an inactive brain) in the
‘supplementary motor area’” (cited in McKean,1981), which would support the argument that
less activity in this brain area would affect all the functional systems it was a part of –
reading, speaking, writing, doing mental mathematics, typing and so on.

According to Luria (1980), the part of the brain where the parietal, occipital and temporal
lobes meet is responsible for allowing people to understand the relations between symbols,
and a dysfunction in this area would also disturb the function called “symbol relations”, which
deals with creating symbolic relationships between objects or concepts (Norman, 2001). A
learning disorder characterized as “reading difficulty” can be described in this way according
to Arrowsmith as a number of several dysfunctions that are interconnected to each other.
Other dysfunctions described include artifactual thinking problems – reading non-verbal
emotional cues important to understanding human behavior, modulated by deficits in the right
frontal cortex; symbol recognition difficulties – dependent on the left occipital area;
mispronouncing of words, dependent on Broca’s area; auditory speech discrimination, also
expressed within Broca’s area; lexical memory difficulties, sustained by a cognitive area
behind Wernicke’s area devoted to remembering the sound of words; spatial reasoning,
depending on premotor areas; kinesthetic perception – perceiving where both sides of the
body are in space, and others.

The Arrowsmith Program Assessment is designed to identify the areas belonging to the 19
learning dysfunctions that are causing learning difficulties. Following the identification of the
dysfunctions, individualized exercises and computerized programs are used to compose
clearly defined goals in order to strengthen the underlying weak cognitive capacities of the
student. The method implies learning in a positive structured and supportive environment,
building self-esteem by developing competence and low student-to-teacher ratio, and is based
on the concept of neuroplasticity in strengthening weak brain areas through cognitive
exercises.

A study (McGuyer, 2011) on primary teacher’s perspectives on teaching reading to students

with dyslexia in the general education classroom concluded that many students with dyslexia
continue to perform far below grade level expectations in reading and writing despite
interventions to attain adequate phonemic awareness skills. The same study found that Orton-
Gillingham methods are an effective intervention, and that general education teachers are
seeking more professional development opportunities to work with students with reading
disabilities. The Barton Reading Program used in this study is an Orton-Gillingham based
program that trains average adults, such as parents, to provide effective intervention to teach
children with dyslexia to read and spell. Mihandoost and colleagues (2011) found that the
motivation and reading fluency of dyslexic students after receiving the Barton intervention
program for three months was satisfactory and significant, as measured through the Reading
Motivation Scale and Reading Fluency Test.

There are also a number of programs that directly and systematically teach students how
letters and sounds relate, which provide focused interventions in spelling rules and reading
fluency (Al Otaiba & Fuchs, 2002; Cassar et al., 2005; Dion et al., 2004; Enns & Lafond,
2007; Lyon & Weiser, 2009; Nelson & Machek, 2007; Pugh et al., 2001; Shaywitz &
Shaywitz, 2007b; Torgesen et al., 2010; Tunmer, 2008; Wise et al., 2007, apud McGuyer,
2011), where the basic principle of most dyslexia interventions is to utilize auditory-based
methods to emphasize pairing speech with written words. Hudson (2007) also maintained,
previous to McGuyer’s study, that it is important for educators to understand dyslexia in the
context of current brain research in order to evaluate and implement effective instructional
strategies to increase student achievement within the classroom.

Many Orton-Gillingham-based programs insist that all students must be taught phonemic
awareness before proceeding to learning phonics, as instruction should only focus on the
skills the reader is capable of learning – it would be ineffective to repeat a concept that is not
within the reader’s linguistic or cognitive repertoire (Barton Reading, 2011). The Orton-
Gillingham intervention should also be designed to match the needs f the child with dyslexia
(Gustafson et al., 2007). For example, children with a phonological weakness respond better
to intervention than those with an orthographic weakness who also received an intervention,
which leads to the conclusion that instruction for children with reading disabilities should
focus on their weakness in word decoding, rather than their strength. Furthermore, Shaywitz
and colleagues (2006) reported that children with dyslexia displayed increased brain
activation in the systems used for reading after receiving instruction based on the alphabetic
code. Reading comprehension, phonemic awareness, nonsense word decoding, and word
recognition in isolation all improve as a result of explicit instruction in the alphabetic code
(Denton, et al., 2008; Lyon & Weiser, 2009; Moats, 2009; Shaywitz et al., 2006; Torgesen,
2007; Tunmer, 2008, apud McGuyer, 2011).

Another common aspect in all the Orton-Gillingham programs is spelling, as poor spelling
and poor reading are highly correlated. Through an analytic approach, children are taught to
look at the whole word and identify patterns that can be divided into smaller parts, such as
onset and rime (Wright & Mullan, 2006). A synthetic approach teaches children to say each
sound in isolation and them blend them together to pronounce the word, which is useful
because it allows children to memorize a larger piece of the word as a unit rather than an
individual sound. The Phono-Graphix program, which differs from both synthetic and
analytic approaches in that it teaches that letters represent sounds, students are first taught to
match one sound to one letter, after which they learn how to blend, segment, and manipulate
sounds in simple three letter words, and finally they blend sounds into syllables and syllables
into words. Phono-Graphix programs were found to improve students’ phonological
processing skills due to a much deeper awareness that a word can be significantly altered by a
deletion, addition or substitution of a single phoneme in the word. During a study following
an 8-month program, 70% of the students made a 21-month gain in reading and a 12-month
gain in spelling (Wright & Mullan, 2006). The students were however still unable at the end
of the program to make the transition to the orthographic spelling stage, where students have
the ability to utilize more visual or meaning based strategies rather than rely on phonetic
spelling.

Improving fluency by strengthening the association between the visual/graphemic elements in

words can be done by using visual identification of syllables in connected text and focusing
on rapid recognition by reading syllables presented at automatic intervals (Tressoldi et al.,
2007). Students that are both dyslexic and deaf and received short, frequent teaching sessions
using the same reading passage for 10 days at a time achieved a significant 6-month gain over
a 6-month time span (Enns & Lafond, 2007). This program also focused on teaching
vocabulary that the students would encountered in other curricular areas, in a meaningful
context. While this might not also improve reading comprehension, the amount of time spent
practicing reading is an important factor to closing the achievement gap in reading fluency.

6. Conclusions

Theories regarding dyslexia are currently conflicting, as most efforts have been focused so far
on investigating different causes of dyslexia. Therefore, dyslexia does not have a single
definition, which makes it difficult to design effective treatments for this disorder. Most
current research presents evidence that a deficit in phonological processing is the primal cause
of dyslexia, but this is not the only element that this disorder presents. Further studies instruct
that phonemic awareness skills need to firstly be explicitly taught to dyslexics, after which a
reading program should focus on elements such as vocabulary, automaticity, repetition,
interest, fluency, syllable instruction and a classroom assistive listening system. Dyslexia and
the term ‘reading impairment’ have been used interchangeably, however in educational
environments the term learning disability is more frequently used. Unless children are
severely dyslexic though, they may not qualify for special education services, as not all
children having a learning disability actually have dyslexia.

Neuroimaging has shown with regards to neuroplasticity that intense interventions that focus
on phonological awareness can improve brain function and word recognition abilities. Genetic
studies have so far shown that there must be different subtypes of dyslexia at a genetic level,
which sustains the argument that brain-based and genetic methods are crucial to be designed
in order to design individually-appropriate remediation and treatment methods. Training
methods and programs that have proposed that intervention should focus on the students’
specific cognitive deficits have mostly been inefficient, as they focused on strategy and
cognitive development and not on neuropsychological approaches in treating dyslexia.
Neuroimaging studies need to be further developed and focused on, as different neural
mechanisms and pathways than those that support gains in reading for typically developing
children are reflected in children with dyslexia.

Successful intervention programs focused so far on alternative strategies in addition to

interventions that build on typical reading instruction. Some of these effective interventions
include Bakker’s neuropsychological intervention approach – from which HAS effectively
improved reading for both groups of children tested; the multisensory approach; extensive
auditory therapy – which showed that auditory training can induce therapeutic neural
plasticity in dyslexia. Studies analyzing Fast ForWord have shown some success in improving
rapid auditory processing, phonological and linguistic training, which resulted in
differentiated activation to rapid and slow transitions, similarly to that of children with typical
development., along with longitudinal positive effects that also included improved writing
skills. The Arrowsmith Program involves the strengthening of cognitive abilities that underlie
each dysfunction, and has received so far limited amount of support from recent research,
which is in accordance with previous studies on the inefficiency of focusing only on training
cognitive deficits. The Orton-Gillingham methods proved however to be effective
interventions.

While there is still no clear consensus on appropriate methods of diagnosis and treatment, and
previous research studies has been done in apparent isolation from others, there clearly needs
to be a convergence in terms of cognitive neuroscience, neuroplasticity findings and
pedagogical methods. These findings advocate for the use of an evidence based intervention
from an early age in order to assist students with dyslexia to develop accurate and fluent
reading, which should also result in increased self-esteem and positive social change.

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brains-for-reading